Potty Training for Children with Challenges

1. Potty Training for Children with Challenges • Christy Moran, OTR • Tasha Heinze, SI • Rachel Harvey, MOM • Chris Asbeck, MOM

2. OBJECTIVES • Participants will understand general potty training • Participants will understand and be able to adapt potty training techniques to meet individual situations and challenges

3. What’s the Big Deal? • Recognize the need to go • Wait to eliminate • Enter the bathroom • Pull down clothing • Sit on the toilet • Eliminate in the toilet • Use the toilet paper correctly • Pull clothing back up • Flush the toilet • Wash hands with soap • Dry hands

4. Where to Start • Start teaching steps 5 and 6 • Sit on the toilet and eliminate in the toilet • You will do steps 1-4 for your child • Recognize the need, wait, enter the bathroom and pull down the clothing • Help your child do steps 7-11 • Toilet paper, flush, pull clothes up, wash and dry hands

5. Is Your Child Ready? Follow simple directions? Sit in a chair for 5 minutes? Dry for 1 ½ hours?

6. Are You Ready? Time Patience Consistency

7. Why Start with BMs? • BM’s are consistent • BM’s are infrequent (once or twice a day) • Diapers are continued during BM training • Less time during the day is needed for BM training for child and parent

8. Let’s GO! • Determine your child’s pattern • Keep a record for 2 weeks • Do not change your routine during this time • Record from the time your child wakes up, every hour if the diaper is wet, soiled, or dry • Use a chart that you only have to check wherever you normally change diapers • This is to establish your child’s pattern of elimination and make your job easier

11. Determine the Schedule • Look at the 2 weeks data • Circle the BM’s on the sheet • Is there a pattern?

13. What Do You See? • This child’s pattern is twice a day – around 9am and 5pm • The focus time would be approximately • 8:45 to 9:05 and 4:45 to 5:05

14. Focus Time(20 minutes) • Put your child on the potty 15min before anticipated BM. (Approx. 8:45am/4:45pm) • Sit for 5min. Praise for sitting • Wait 10min, if not had BM, put your child back on the potty for 5min • Again - Praise for sitting

16. Keeping Records • During the first week do not alter the plan • Record when your child sits on the potty (we use x for sitting only) • Record when your child has a BM in the potty (P – BM in the potty!!!!!!) • Record when your child has a BM in the diaper (D – BM in the diaper and what time the BM occured)

18. Checking ProgressDo We Need to Change? • Are the BM’s still around the anticipated time? • If yes – keep the same plan • Is your child consistently earlier or later than the focus time? • If yes – consider altering the time to better match your child’s body schedule

19. Consistency • Follow the plan every day • Praise for sitting on the potty • Bigger praise for BM in the potty • During this time do not try to urine train • IF your child asks to go to the potty during other times of the day it is OK

20. Time for a Change?

21. Is Your Child Ready to Urine Train? • Begin Urine Training when your child consistently has a BM in the first sitting of toileting times • And they have no more than one BM in the diaper during a typical week

22. Are You Ready To Urine Train? • Change your child from diapers to training pants during the day • You may want to “double up” on the undies since this may be messy • Children are comfortable wetting in diapers. We need to remove this comfort to be successful. Now comfort comes from staying dry by way of wetting in the potty

23. Urine Training • Determine a schedule of when your child is most likely to urinate • Look at two weeks data of when they have wet diapers • Circle the U’s on your chart • Find 4 to 6 times a day when they are likely to urinate • Add those times to the schedule you already have

25. New Schedule • This child has 4 times they are likely to urinate – 7am, 11am, 2pm, and 7pm • Add those times to your new schedule • Use the same focus times as before – start 15 minutes before anticipated urination, sit for 5 min, praise for sitting, 10 min later if still dry, sit for 5 min, praise for sitting

27. Record Keeping Again • During the first week do not alter the plan • Record when your child sits on the potty (we use x for sitting only) • Record when your child urinates (U) or has a BM • Record if it is in the potty (P) or in the training pants/diaper (D)

29. Do We Need to Change? • Are the U’s still around the anticipated times? • If yes – keep the same plan • Is your child consistently earlier or later than the focus time? • If yes – consider altering the time to better match your child’s body schedule

30. Consistency • Follow the plan every day • Do not change the plan the first week • Use the same words/signs/pictures • Use the same toilet if you can. • If your child shows signs of a BM (squatting, straining, going behind the sofa) or needing to urinate (holding themselves, crossing legs) at other times, go ahead and let him potty

31. Rewards • Use rewards to increase desired behavior • Start small – for just sitting on the potty • Work up to sitting for 5 minutes • Then give for eliminating in the potty • Use immediate rewards – praise, high fives, hugs, stickers, goldfish crackers, teddy grahams • Have them close by (immediate)

32. Reward or Not? • Decide ahead of time what gets reward • Make it easy to achieve • IF they do not do the behavior – do not give a reward • Quietly lead your child out of the bathroom • Do not talk about the missed reward

33. No Attention (?) • When they soil or wet their diaper/pants - quietly change them in the bathroom • Try to focus on changing without making eye contact or talking to your child • Then quietly lead them out of the bathroom • If your child is given attention for accidents they are likely to continue

34. More Keys to Success • Use the regular toilet from the start • If your child is too small, use a smaller seat that sits over the regular one • Have a stool/bench to help your child get onto the toilet and to place their feet on while on the toilet. This will help them feel more secure, and relax better. • If you use a potty chair, keep it in the bathroom

35. Even More Keys to Success • Limit distractions in the bathroom • Talk about the toilet and what you want your child to do in a concise, non-demanding way • Sing a potty song • Wait patiently • Give reinforcements • Do not turn it into “playtime with mommy”

36. Phasing Yourself Out • When your child is consistent with sitting on the potty, begin to phase yourself out • Start by attending to other things in the bathroom • Then wait at the door • Then leave the bathroom, start brief then gradually go for longer periods of time

37. Phasing Out Rewards • As your child is beginning to use the potty with consistency begin phasing out the rewards • IF you have done stickers or food, begin to give them less often or move to High Fives • Continue to tell your child that you are proud of him for going to the potty

38. Adaptations

39. Positioning • IF your child has high or low muscle tone, or if they seem to be “wobbly” and lean often when sitting make sure their feet are on a firm surface, like a wooden stool • They may need arm rests, or to hold onto the counter/wall • They may need to sit facing the back, straddling the toilet, with arms on tank • This is also good for boys to learn aiming

40. Picture Schedules • If your child learns better from pictures than from words you may want to have a picture schedule for toilet training • It should be brief but contain the information your child needs • It could be in a book format for reading OR in line format that you have on the bathroom wall easily visible from the toilet

42. Vision Impairment • The same readiness signs apply • Follow simple directions • Sit in a chair for 5 minutes • Stays dry for 1 ½ hours • The same positioning tips apply • Have a firm surface for their feet – wood bench

43. Looking With Your Hands • The child with severe vision impairment will need to touch and feel the toilet and toilet paper with your hands guiding them • They may need to touch the bowel movement or urine to understand • This is ok at the beginning but should not become a part of the regular routine

44. Constipation • Liquid Intake • Most children need 1 ½ ounces of fluid per pound of body weight • Hot weather, fever, and excessive drooling can cause that to go to 2-3 ounces per pound • Fiber Intake • Add fiber to your child’s diet through fresh fruits, vegetables, whole grains, and cooked beans

45. Daycare / Preschool

46. What Do They Do? Habit Training Token System Potty Day

47. Habit-Training Program • Once a day (usually in the morning) the child drinks liquid (2-4oz) prior to toileting • The child sits on the toilet until they urinate in the toilet. (Up to 30 minutes) They may need to stand up or walk in the bathroom a minute • If they have not urinated within 5-10 minutes more liquid is given (8-10oz) while on the toilet

48. What Else? • Wait until the child urinates. • When the child starts to urinate stay quiet, then praise them for urinating in the toilet. • IF they have an accident while they are standing, try to catch it in a cup and put it in the toilet. Do Not scold. • Do this once a day until they are urinating within 2-3 minutes of getting on the potty

49. Continuing • Add toilet times during the day • Start with one additional, then when they are urinating within 2-3 minutes each time add another • Eventually your child should urinate whenever you put them on the potty. This means that they are “Habit Trained”

50. Moving to Independent • Once your child is habit trained, teach words, signs, or use of pictures so they can let you know when they need to potty • Give them reminders or suggestions but do not take them until they ask. When they have accidents change them in the bathroom as quietly as you can without giving attention